Inspection Reports for Holy Angel Care Home
1517 Gentle Brook Street N., North Las Vegas, NV 89084, NV, 89084
Back to Facility ProfileDeficiencies per Year
8
6
4
2
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Annual Inspection
Census: 4
Capacity: 10
Deficiencies: 0
May 29, 2025
Visit Reason
This inspection was conducted as an annual State Licensure inspection in accordance with Nevada Administrative Code (NAC) Chapter 449 for Residential Facility for Groups.
Findings
The facility received a grade of A with no regulatory deficiencies identified. Four resident files and five employee files were reviewed, and no further action was necessary.
Report Facts
Resident files reviewed: 4
Employee files reviewed: 5
Inspection Report
Annual Inspection
Census: 5
Capacity: 10
Deficiencies: 0
Apr 22, 2024
Visit Reason
The inspection was conducted as an annual State Licensure inspection in accordance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.
Findings
The facility received a grade of A with no regulatory deficiencies identified. Five resident files and four employee files were reviewed, and no further action was necessary.
Inspection Report
Annual Inspection
Census: 4
Capacity: 10
Deficiencies: 4
Apr 20, 2023
Visit Reason
The inspection was conducted as an annual State Licensure survey in accordance with Nevada Administrative Code Chapter 449 for a Residential Facility for Groups.
Findings
The facility was found to have multiple deficiencies including inaccurate Medication Administration Records for two residents, a non-functioning audible door alarm, accessible sharp objects, and accessible toxic substances. Several deficiencies were repeat findings from the previous year's survey.
Severity Breakdown
E: 1
F: 3
Deficiencies (4)
| Description | Severity |
|---|---|
| Medication Administration Record (MAR) was inaccurate for 2 of 4 sampled residents, with discrepancies between physician orders, medication labels, and MAR documentation. | E |
| Alarm system on the front door was not audible and functioning. | F |
| Sharp objects such as a chainsaw and gas powered tree trimmer were accessible to residents. | F |
| Toxic substances including a canister of gasoline and a spray canister of weed killer were accessible to residents. | F |
Report Facts
Licensed beds: 10
Resident census: 4
Deficiency repeat: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Trina M Anderson | Administrator | Named as responsible for corrective actions and signed the report |
Inspection Report
Re-Inspection
Census: 3
Capacity: 10
Deficiencies: 0
Jul 18, 2022
Visit Reason
This inspection was a mandatory grading resurvey conducted at the facility in accordance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.
Findings
No regulatory deficiencies were identified during the inspection. The facility received a grade of A. Several regulatory requirements related to elder abuse training, personnel files, health and sanitation, medication administration, and Alzheimer's care standards were reviewed with no deficiencies cited.
Report Facts
Licensed beds: 10
Resident census: 3
Inspection Report
Annual Inspection
Census: 4
Capacity: 10
Deficiencies: 7
Apr 26, 2022
Visit Reason
Annual State Licensure and infection control survey conducted in accordance with Nevada Administrative Code Chapter 449 for a Residential Facility for Groups.
Findings
The facility was found deficient in multiple areas including elder abuse training, personnel background checks, first aid and CPR certification, medication administration documentation, facility maintenance, and safety standards for Alzheimer's care. Several deficiencies were cited with severity levels ranging from 2 to 3, and the facility received a grade of C.
Severity Breakdown
2: 7
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to ensure 1 of 4 sampled employees completed initial elder abuse training before providing services. | 2 |
| Failed to maintain current criminal background checks every five years for 2 of 3 sampled employees. | 2 |
| Failed to ensure 1 of 3 sampled employees had current certification in First Aid and CPR. | 2 |
| Failed to maintain clean and well-maintained exterior grounds; observed dog feces, inoperable treadmill, and broken patio furniture. | 2 |
| Failed to document all medications on Medication Administration Record for 2 of 4 sampled residents. | 2 |
| Failed to ensure audible alarm systems were activated on 2 of 3 exit doors. | 2 |
| Failed to ensure toxic substances were not accessible to residents; found unlocked cleaning products. | 2 |
Report Facts
Licensed beds: 10
Current census: 4
Deficiencies cited: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cynthia Morris | Administrator | Signed the report and mentioned as administrator responsible for compliance |
| Employee #1 | Caregiver | Failed to complete initial elder abuse training and CPR/First Aid certification |
| Employee #2 | Owner | Lacked current criminal background check |
| Employee #3 | Owner | Lacked current criminal background check |
Inspection Report
Annual Inspection
Census: 4
Capacity: 10
Deficiencies: 7
Apr 26, 2022
Visit Reason
This inspection was conducted as an annual State Licensure and infection control survey for a Residential Facility for Groups, in accordance with Nevada Administrative Code (NAC) Chapter 449.
Findings
The facility received a grade of C with multiple deficiencies identified including failure to ensure elder abuse training completion, incomplete background checks, lack of CPR certification, poor health and sanitation conditions, medication administration documentation errors, and failure to maintain audible alarm systems and secure toxic substances.
Severity Breakdown
Severity: 1: 1
Severity: 2: 6
Deficiencies (7)
| Description | Severity |
|---|---|
| Failure to ensure 1 of 4 sampled employees completed initial elder abuse training before providing services. | Severity: 2 |
| Failure to maintain current criminal background checks every five years for 2 of 3 sampled employees. | Severity: 2 |
| Failure to ensure 1 of 3 sampled employees had current certification in First Aid and CPR. | Severity: 1 |
| Failure to maintain the exterior of the facility including piles of dog feces, inoperable treadmill, and broken patio furniture. | Severity: 2 |
| Failure to document all medications on Medication Administration Records for 2 of 4 sampled residents. | Severity: 2 |
| Failure to ensure audible alarm system was activated on 2 of 3 exit doors. | Severity: 2 |
| Failure to ensure toxic substances were secured and inaccessible to residents. | Severity: 2 |
Report Facts
Residents present: 4
Licensed capacity: 10
Deficiencies cited: 7
Inspection Report
Re-Inspection
Census: 6
Capacity: 10
Deficiencies: 6
Nov 19, 2021
Visit Reason
This inspection was a grading resurvey conducted to assess compliance with Nevada Administrative Code Chapter 449 for Residential Facilities for Groups, following a prior survey with identified deficiencies.
Findings
The facility received a grade of A but had several repeat deficiencies including failure to ensure annual tuberculosis screening and physical exams for residents, as well as issues related to medication administration accuracy, maintenance of resident files, and Alzheimer’s care safety standards.
Severity Breakdown
D: 2
E: 1
F: 3
Deficiencies (6)
| Description | Severity |
|---|---|
| Failure to ensure an annual tuberculosis (TB) screening was completed for 1 of 6 residents (Resident #3). | D |
| Failure to ensure a physical exam was completed annually for 1 of 6 residents (Resident #4). | D |
| Medication administration accuracy and reporting deficiencies. | F |
| Administration of medication maintenance and contents of logs and records deficiencies. | E |
| Maintenance and contents of separate file for each resident deficiencies. | F |
| Alzheimer's care standards for safety deficiencies, including ensuring toxic substances are not accessible to residents. | F |
Report Facts
Licensed beds: 10
Current census: 6
Repeat deficiencies: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cynthia Ann Morris | Executive Director | Named as Executive Director responsible for monthly chart audits and corrective actions |
Inspection Report
Annual Inspection
Census: 6
Capacity: 10
Deficiencies: 7
Aug 3, 2021
Visit Reason
The inspection was conducted as an annual state licensure and infection control survey for a Residential Facility for Groups for persons with Alzheimer's disease, Category II residents.
Findings
The facility was found deficient in multiple areas including incomplete tuberculosis (TB) testing for employees and residents, expired CPR and first aid training for an employee, lack of required physical examinations for residents, failure to complete medication reviews every six months, inaccurate medication administration records, failure to maintain complete resident files, and unsecured toxic substances accessible to residents.
Severity Breakdown
Level 2: 7
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to ensure 3 of 4 employees met TB testing requirements; lacked documented evidence of two-step TB tests. | Level 2 |
| Failed to ensure 1 of 4 employees had current CPR and first aid training; training was expired. | Level 2 |
| Failed to ensure 4 of 6 residents had a physical examination signed by a physician. | Level 2 |
| Failed to ensure medication reviews were completed every six months for 6 of 6 residents. | Level 2 |
| Failed to maintain accurate Medication Administration Records for 3 of 6 residents. | Level 2 |
| Failed to ensure 4 of 6 residents met TB testing requirements; lacked documented evidence of two-step TB tests prior to admission. | Level 2 |
| Failed to ensure toxic substances were inaccessible to residents; chemicals were unsecured in pantry. | Level 2 |
Report Facts
Facility licensed beds: 10
Resident census: 6
Employees reviewed: 4
Resident files reviewed: 6
Deficiency severity counts: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cynthia Morris | Executive Director | Named in relation to oversight and tracking of compliance and deficiencies |
| Rochelle Santos | Owner | Named in relation to oversight and tracking of compliance and deficiencies |
| Employee #2 | Acknowledged expired CPR training, medication administration issues, and unsecured chemicals | |
| Employee #1 | Referenced in TB testing deficiency | |
| Employee #3 | Referenced in TB testing deficiency |
Inspection Report
Abbreviated Survey
Census: 4
Capacity: 10
Deficiencies: 1
Nov 23, 2020
Visit Reason
This inspection was a COVID-19 focused infection control survey conducted to assess the facility's compliance with infection control measures during the pandemic.
Findings
The facility had no residents or staff with COVID-19 symptoms or positive results. However, deficiencies were found including failure to screen the health facility inspector with COVID-19 questions prior to entry, lack of comprehensive infection control policies addressing staff fit testing for N95 masks and emergency staffing plans, and no employees medically cleared or fit tested to wear N95 masks.
Severity Breakdown
Severity: 2: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Administrator did not ensure the health facility inspector was screened with COVID-19 questions prior to entry; facility lacked comprehensive infection control policies; failed to ensure one employee was medically cleared and fit tested to wear N95 mask. | Severity: 2 |
Report Facts
Licensed capacity: 10
Census: 4
Inventory counts: 6
Inventory counts: 10
Inventory counts: 3
Inventory counts: 50
Inventory counts: 4
Inventory counts: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cynthia Morris | Executive Director | Signed report as Laboratory Director or Provider/Supplier Representative |
Inspection Report
Annual Inspection
Census: 2
Capacity: 10
Deficiencies: 3
Dec 17, 2019
Visit Reason
This inspection was conducted as an annual survey of the facility in accordance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.
Findings
The facility received a grade of A. Deficiencies were identified related to failure to post meal substitutions, unsecured oxygen tanks, and medication label discrepancies not matching physician orders.
Severity Breakdown
C: 1
D: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Facility failed to post substitutions to the menu as required. | C |
| Facility failed to ensure oxygen tanks were secured. | D |
| Medication label prepared by pharmacy did not match the physician's order for one resident. | D |
Report Facts
Deficiencies cited: 3
Resident files reviewed: 2
Employee files reviewed: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rosallen Azucena | RFA | Laboratory Director's or Provider/Supplier Representative's signature on report |
Inspection Report
Complaint Investigation
Census: 3
Capacity: 10
Deficiencies: 3
Aug 12, 2019
Visit Reason
The inspection was conducted as a result of a complaint investigation initiated on 2019-08-05 and finalized on 2019-08-12 regarding allegations involving the Administrator and Caregiver.
Findings
The complaint was substantiated without deficiency; however, unrelated deficiencies were identified including failure to generate an incident report for a resident who wandered, failure to provide an annual physical examination for a resident, and failure to ensure all exit doors had operational alarms.
Complaint Details
Complaint #NV00057964 was substantiated without deficiency. The allegation involved a verbal altercation between the Administrator and Caregiver and the Administrator pulling their license and employee records without notice.
Severity Breakdown
Level 2: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to generate an incident report when Resident #2 wandered out of the facility in May 2019. | Level 2 |
| Failure to ensure Resident #3 was provided an annual physical examination in 2019. | Level 2 |
| Failure to ensure all exit doors were equipped with alarms that activated when opened; alarms were found turned off on multiple doors. | Level 2 |
Report Facts
Licensed beds: 10
Residents present: 3
Complaints investigated: 1
Severity 2 deficiencies: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cynthia Morris | Administrator | Named in relation to the inspection and findings |
Inspection Report
Annual Inspection
Census: 5
Capacity: 10
Deficiencies: 4
Jan 3, 2019
Visit Reason
This annual survey was conducted as a State Licensure Survey in accordance with Nevada Administrative Code (NAC) Chapter 449 for a Residential Facility for Groups licensed for persons with Alzheimer's disease.
Findings
The facility received a grade of A but had several deficiencies including failure to ensure one caregiver completed required medication management training, failure to destroy expired medications, failure to secure medications properly, and failure to ensure one of three exit door alarms activated when the door was opened.
Severity Breakdown
2: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Facility failed to ensure one of three caregivers completed the initial 16-hour medication management training. | 2 |
| Facility failed to destroy expired medications found in a resident's bathroom medicine cabinet. | 2 |
| Facility failed to ensure medications were secured; unsecured expired medications were found in a resident's bathroom medicine cabinet. | 2 |
| Facility failed to ensure one of three exit door alarms activated when the door was opened. | 2 |
Report Facts
Census: 5
Total licensed capacity: 10
Medication training hours: 16
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #3 | Named in deficiency for not completing initial medication management training | |
| Employee #1 | Interviewed and verbalized medication and alarm issues |
Inspection Report
Re-Inspection
Deficiencies: 0
Jan 26, 2016
Visit Reason
This document is a required grading re-survey conducted at the facility on 01/26/2016 as part of a State Licensure survey by the Division of Public and Behavioral Health.
Findings
No deficiencies were identified during this re-survey, and the facility received a re-survey grade of A.
Inspection Report
Annual Inspection
Census: 6
Capacity: 10
Deficiencies: 7
Nov 24, 2015
Visit Reason
This inspection was conducted as an annual State Licensure survey to assess compliance with regulatory requirements for a residential facility for persons with Alzheimer's disease.
Findings
The facility received a grade of C with multiple deficiencies identified including failure to ensure employees received annual elder abuse training, incomplete tuberculosis testing documentation, incomplete background checks, failure to ensure residents received required physical examinations, inaccurate medication administration records, unsecured dangerous items, and unsecured yard fencing.
Severity Breakdown
Level 1: 1
Level 2: 6
Deficiencies (7)
| Description | Severity |
|---|---|
| Failure to ensure 2 of 5 employees acquired annual Elder Abuse training. | Level 2 |
| Failure to ensure 2 of 5 employees met tuberculosis testing requirements. | Level 2 |
| Failure to ensure 3 of 5 employees met background check requirements. | Level 2 |
| Failure to ensure 3 of 6 residents received initial or annual physical examinations. | Level 2 |
| Failure to ensure Medication Administration Records were accurate for 3 of 6 MARs reviewed. | Level 2 |
| Failure to ensure dangerous items (knives, razor blade, staple remover) were inaccessible to residents. | Level 1 |
| Failure to ensure all gates leading from secured fenced area were locked and keys readily available. | Level 2 |
Report Facts
Licensed capacity: 10
Census: 6
Employees reviewed: 5
Resident files reviewed: 6
Inspection Report
Annual Inspection
Census: 6
Capacity: 10
Deficiencies: 7
Nov 24, 2015
Visit Reason
This document is an annual State Licensure survey conducted to assess compliance with regulatory requirements for the facility licensed as a Residential Facility for Group beds providing care to persons with Alzheimer's disease.
Findings
The facility received a grade of C with multiple deficiencies identified including failure to ensure annual elder abuse training for employees, incomplete tuberculosis testing documentation, incomplete background checks, missing or delayed physical examinations for residents, inaccurate medication administration records, unsecured dangerous items accessible to residents, and unlocked gates leading from secured areas.
Severity Breakdown
E: 2
F: 4
C: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Failure to ensure 2 of 5 employees acquired annual Elder Abuse training. | E |
| Failure to ensure 2 of 5 employees met tuberculosis testing requirements. | E |
| Failure to ensure 3 of 5 employees met background check requirements. | F |
| Failure to ensure 3 of 6 residents received initial or annual physical examinations timely. | F |
| Failure to ensure Medication Administration Records were accurate for 3 of 6 residents. | C |
| Failure to ensure dangerous items were inaccessible to residents; unsecured knives, staple remover, and letter opener observed. | F |
| Failure to ensure all gates leading from the secured area were locked. | F |
Report Facts
Deficiencies cited: 7
Census: 6
Total Capacity: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #1 | Named in findings related to tuberculosis testing and background check deficiencies. | |
| Employee #2 | Named in findings related to tuberculosis testing and fingerprint submission delay. | |
| Employee #3 | Acknowledged missing documentation and confirmed deficiencies during interviews. | |
| Employee #4 | Named in findings related to missing annual elder abuse training and background check deficiencies. | |
| Employee #5 | Named in findings related to missing annual elder abuse training and background check deficiencies. |
Inspection Report
Original Licensing
Capacity: 10
Deficiencies: 0
Nov 18, 2014
Visit Reason
This document is a Statement of Deficiencies generated as a result of an initial State licensure survey conducted on 11/18/2014 for the facility requesting licensure for ten Residential Facility for Group beds for elderly and disabled persons.
Findings
One employee file and one resident file were reviewed during the survey. The document does not specify any deficiencies cited or findings beyond the initial licensure survey process.
Report Facts
Licensed capacity: 10
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